NICE guidance and implementation

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NICE guidance and implementation
Meeting 18 weeks and other challenges

• Gillian Mathews
• Implementation Consultant, NICE

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Todays journey

• Introducing NICE
• Guidance and cardiac disease
• Care pathways and 18 weeks
• Implementing guidance
• The way forward

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What is NICE?

• The National Institute for Health and Clinical
  Excellence (NICE) is the independent organisation
  responsible for providing national guidance on
  the promotion of good health and the prevention
  and treatment of ill health.

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We produce guidance in three areas

• Public health guidance on the promotion of good
  health and the prevention of ill health for those
  working in the NHS, local authorities and the
  wider public and voluntary sector
• Health technologies guidance on the use of new
  and existing medicines, treatments and procedures
  within the NHS
• Clinical practice guidance on the appropriate
  treatment and care of people with specific
  diseases and conditions within the NHS.

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Core principles of all NICE guidance

• Comprehensive evidence base
• Expert input
• Patient and carer involvement
• Independent advisory committees
• Genuine consultation
• Regular review
• Open and transparent process.

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Technology appraisals

• Cardiac related appraisals include...
• Heart failure - cardiac resynchronisation
• Acute coronary syndromes clopidogrel
• Angina and myocardial infarction myocardial
  perfusion scintigraphy
• Cardiovascular disease statins
• Dual-chamber pacemakers for the treatment of
  symptomatic bradycardia
• Myocardial infarction thrombolysis
• Arrhythmia - implantable cardioverter
  defibrillators (ICDs)
• Acute coronary syndromes - glycoprotein IIb/IIIa
  inhibitors
• Ischaemic heart disease coronary artery stents

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Assessing Cost Effectiveness
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Probability of rejection
0
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Cost per QALY (000)
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Coronary artery stents (review) Final appraisal
determination

• Drug-eluting stents are recommended for use in
  percutaneous coronary intervention for the
  treatment of coronary artery disease, within
  their instructions for use, only if
• the target artery to be treated has less than a 3
  mm calibre or the lesion is longer than 15 mm,
• and
• the price difference between drug-eluting stents
  and bare-metal stents is no more than 300.
• This FAD is now subject to one appeal, which will
  be heard on 14 April 2008.
• Final guidance will published following the
  outcome of the appeal

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Interventional Procedures

• Some cardiac IPs
• Short-term circulatory support with left
  ventricular assist devices as a bridge to cardiac
  transplantation or recovery
• Dynamic cardiac monitoring
• Cryoablation for atrial fibrillation in
  association with other cardiac surgery (also
  radiofrequency, microwave and high intensity
  focused ultrasound ablation)
• Endoaortic balloon occlusion for cardiac surgery
• Balloon dilatation of pulmonary valve stenosis
• Balloon valvuloplasty for aortic valve stenosis
  in adults and children
• Partial left ventriculectomy (the Batista
  procedure)
• and many more

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Implementing Interventional Procedures Guidance

• IP guidance addresses the safety and efficacy of
  interventional procedures not their cost
  effectiveness

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Clinical guidelines

• Completed guidelines
• Chronic heart failure
• Hypertension
• Myocardial infarction secondary prevention
• Type 1 diabetes
• Type 2 diabetes
• Atrial fibrillation
• Prevention of venous thromboembolism (surgical
  inpatients)
• Guidelines in development
• Lipid modification
• Acute chest pain
• Prevention of venous thromboembolism (all
  patients)

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What has all that got to do with 18 weeks?
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Secondary prevention of MI

• Lifestyle
• Cardiac rehabilitation after an acute MI
• Drug therapy after an MI in the last 12 months
• Drug therapy after a proven MI in the past
  (more than 12 months ago)

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Recommendation reminders
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Core tasks
Translating evidence Recommendations
Implementation/change in practice
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The implementation programme
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What are the main barriers to implementation?

• Clinician distrust
• Lack of organisational support - structures and
  processes
• Resources (or lack of them)

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The NICE implementation programme

• Three key aims - to
• Motivate and inspire
• Provide practical support
• Evaluate impact and uptake

Local leadership is essential
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Motivating - integrating

• Clear, easily accessible guidance
• IT systems
• Education CPD
• Financial arrangements funding direction,
  tariff and the QoF
• Practice-based commissioning
• Inspection processes

Embed in important relevant initiatives
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Practical support

• How to guide and How to change practice
• Educational tools
• Forward planner
• Shared learning database
• Commissioning guides
• Topic specific tools
• Implementation consultants

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Implementation Consultants

• Six consultants based in the field - the local
  face of NICE
• Providing people implementing NICE guidance with
  updates, advice and support for local
  implementation strategies

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Costing tools
Cost of optimum care less cost of current care
resource impact Resource impact can be either
a cost () or saving (-)
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Cardiac resynchronisation therapy for heart
failure
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Key factors driving uptake of new medicines in
acute trusts
High Importance
NICE
Clinical attitudes and preference
Funding and financial status
National priorities
Pharma Industry activity
Patient preference and advice
Low Importance
From Medicines and Industry Strategy Group
report
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Inspection results - appraisals
Self assessment results NHS Trusts
Source The Healthcare Commission, Annual Health
Check
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Evaluating uptake

• Evaluation and Review of NICE Implementation
  Evidence (ERNIE)
• Searchable database providing information on the
  implementation and uptake of NICE guidance
• Studies graded as
• practice appears to be in line with guidance
• practice appears not to be in line with guidance
• doubts about or mixed impact

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Hypertension guideline
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HCC Service Review on Heart Failure
Evidence-based treatment and monitoring
Processes to assess the broader needs of
patients were generally comprehensive and in line
with the recommendations in the NICE guideline.
Outcomes for patients wide variation in the
level of observed adjusted re-admission and
mortality across PCTs in England. such
variation reinforces the need to apply the NICE
guidelines much more assertively.
Source The Healthcare Commission, Service Review
on Heart Failure (July 2007)
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The way forward

• NICE guidance can help your service to run better
• Commissioners are becoming more interested in
  compliance
• Implementation efforts are required at a national
  and local level
• Use the implementation tools to support the
  local strategy
• Please ask us for help!

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Questions and discussion

• gillian.mathews_at_nice.org.uk
• fieldteam_at_nice.org.uk
• www.nice.org.uk